CRRT的局部枸櫞酸抗凝

1、持續(xù)腎臟替代治療的局部枸櫞酸抗凝持續(xù)腎臟替代治療的局部枸櫞酸抗凝北京協(xié)和醫(yī)院杜斌ICU中的急性腎臟功能衰竭中的急性腎臟功能衰竭*: BEST Kidney患病率n1738/29269 (5.7%, 95%CI 5.5 6.0%)危險(xiǎn)因素n感染性休克(47.5%, 95%CI 45.2 49.5%)住院病死率n60.3% (95%CI 58.0 62.6%)*少尿( 84 mg/dL)Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients: a multinational, mul

2、ticenter study. JAMA 2005; 294: 813-818急性腎功能衰竭的定義急性腎功能衰竭的定義: RIFLE標(biāo)準(zhǔn)標(biāo)準(zhǔn)GFR標(biāo)準(zhǔn)UO標(biāo)準(zhǔn)Risk肌酐增加x 1.5或GFR降低 25%UO 50%UO 75%UO 4周ESRD終末期腎病 3月Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure: definition, outcome measures, animal models, fluid therapy and information technology needs: the Second Intern

3、ational Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004; 8: R204-R212ICU的急性腎臟損傷的急性腎臟損傷(AKI)Ostermann M, Chang RWS. Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 2007; 35: 1837-184335.8%急性腎功能衰竭的治療急性腎功能衰竭的治療(n = 646)Perez-Va

4、ldivieso JR, Bes-Rastrollo M, Monedero P, et al. Prognosis and serum creatinine levels in acute renal failure at the time of nephrology consultation: an observational cohort study. BMC Nephrology 2007; 8: 14-22持續(xù)腎臟替代治療管路壽命持續(xù)腎臟替代治療管路壽命滿足治療要求降低治療費(fèi)用減少重新安裝管路的護(hù)理時(shí)間18 30 hr1. Holt AW, Bierer P, Glover P, P

5、lummer JL, Bersten AD. Conventional coagulation and thromboelastograph parameters and longevity of continuous renal replacement circuits. Intensive Care Med 2002; 28: 1649-55.2. Stefanidis I, Hagel J, Frank D, Maurin N. Hemostatic alterations during continuous venovenous hemofiltration in acute rena

6、l failure. Clin Nephrol 1996; 46(3): 199-205.3. Kox WJ, Rohr U, Waurer H. Practical aspects of renal replacement therapy. Int J Artif Organs 1996; 19: 100-5.4. Tan HK, Baldwin I, Bellomo R. Continuous veno-venous haemofiltration without anticoagulation in high-risk patients. Intensive Care Med 2000;

7、 26: 1652-7.持續(xù)腎臟替代治療的影響因素持續(xù)腎臟替代治療的影響因素血管通路位置中心靜脈導(dǎo)管: 口徑, 管腔設(shè)計(jì)血流可靠性血濾管路設(shè)計(jì)透析膜的生物相容性護(hù)理人員的培訓(xùn)及專業(yè)技能抗凝效果持續(xù)腎臟替代的抗凝持續(xù)腎臟替代的抗凝血濾濾器與管路的抗凝作用全身抗凝有害作用持續(xù)腎臟替代的抗凝選擇持續(xù)腎臟替代的抗凝選擇基礎(chǔ)疾病現(xiàn)有抗凝措施臨床經(jīng)驗(yàn)國(guó)內(nèi)文獻(xiàn)報(bào)告的抗凝方法國(guó)內(nèi)文獻(xiàn)報(bào)告的抗凝方法抗凝方法抗凝方法病例數(shù)病例數(shù)(%)單藥抗凝普通肝素844 (37.9)低分子肝素686 (30.8)枸櫞酸26 (1.2)聯(lián)合抗凝普通肝素+低分子肝素483 (21.7)普通肝素+枸櫞酸52 (2.3)無(wú)抗凝137

8、(6.1)CRRT時(shí)的肝素抗凝時(shí)的肝素抗凝出血危險(xiǎn)負(fù)荷劑量IU/kg維持劑量IU/kg/hrAPTTsecACTsec無(wú)危險(xiǎn)性5010 2060 250危險(xiǎn)較小15 255 1045160 180危險(xiǎn)較大102.5 530120肝素抗凝的優(yōu)缺點(diǎn)肝素抗凝的優(yōu)缺點(diǎn)優(yōu)點(diǎn)最常用的抗凝方法臨床方案成熟半衰期短過(guò)量時(shí)魚精蛋白對(duì)抗缺點(diǎn)出血危險(xiǎn)APTT與濾器壽命無(wú)關(guān)肝素誘導(dǎo)血小板缺乏(HIT)枸櫞酸抗凝的原理枸櫞酸抗凝的原理局部枸櫞酸抗凝的原理局部枸櫞酸抗凝的原理凝血過(guò)程需要游離鈣參與枸櫞酸螯合游離鈣, 補(bǔ)充鈣離子可以恢復(fù)血庫(kù)使用枸櫞酸保存血液采用枸櫞酸可以在RRT時(shí)進(jìn)行局部抗凝:n血液進(jìn)入體外循環(huán)后即加入枸

9、櫞酸n血液進(jìn)入體內(nèi)前補(bǔ)充游離鈣n體外循環(huán)對(duì)血液進(jìn)行抗凝, 體內(nèi)血液正常n通過(guò)測(cè)定游離鈣監(jiān)測(cè)抗凝肝素抗凝時(shí)的濾器中空纖維肝素抗凝時(shí)的濾器中空纖維Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int低分子肝素抗凝時(shí)的濾器中空纖維低分子肝素抗凝時(shí)的濾器中空纖維Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood me

10、mbrane interactions during hemodialysis. Kidney Int枸櫞酸抗凝時(shí)的濾器中空纖維枸櫞酸抗凝時(shí)的濾器中空纖維Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int血濾終止的原因血濾終止的原因枸櫞酸(n = 36)肝素(n = 43)管路凝血6 (16.7%)23 (53.5%)改為IHD1 (2.8%)0血管通路問(wèn)題2 (5.6%)0管路斷裂或滲漏1 (2

11、.8%)0管路打折1 (2.8%)0轉(zhuǎn)運(yùn)至放射科或手術(shù)室8 (22.2%)8 (18.6%)濾器壓力高1 (2.8%)2 (4.7%)其他原因16 (44.4%)10 (23.3%)Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367濾器壽命的濾器壽命的Cox風(fēng)

12、險(xiǎn)比例模型分析風(fēng)險(xiǎn)比例模型分析HR95%CIP值枸櫞酸0.3710.197 0.6990.002LOD評(píng)分1.2671.138 1.411 0.001女性0.5240.314 0.8740.01AT-III水平0.2140.065 0.7120.01Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int

13、 2005; 67: 2361-2367出血或輸血的比例出血或輸血的比例枸櫞酸肝素相對(duì)危險(xiǎn)度P值明確或隱性出血0.01 (0 0.04)0.13 (0.04 0.23)0.17 (0.03 1.04)0.06輸注RBC0.17 (0.10 0.25)0.33 (0.18 0.49)0.53 (0.24 1.20)0.13輸注FFP0.40 (0.29 0.52)0.08 (0.01 0.16)4.95 (0.47 52.3)0.18Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic he

14、parin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367CRRT時(shí)出血的多因素時(shí)出血的多因素Poisson回歸回歸RR95%CIP值截距0.0010.00001 0.1740.008枸櫞酸0.1370.020 0.9590.05LOD評(píng)分0.9240.571 1.4940.75AT-III水平6.6470.789 56.0030.08Kutsogiannis DJ, Gibney RTN, Stollery D et al.

15、Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367不同抗凝方法的濾器壽命不同抗凝方法的濾器壽命Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal repla

16、cement in critically ill patients. Kidney Int 2005; 67: 2361-2367枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案枸櫞酸局部抗凝圖示枸櫞酸局部抗凝圖示RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣枸櫞酸局部抗凝方案說(shuō)明枸櫞酸局部抗凝方案說(shuō)明血濾機(jī)常規(guī)預(yù)沖n肝素鹽水根據(jù)患者病情選擇適當(dāng)治療模式nCVVHnCVVHDnCVVHDF枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案準(zhǔn)備枸櫞酸抗凝液n血液保存液(I) 600 ml/袋n廣州華南醫(yī)療用品有限公司成分成分分子量分子量含量含量(g)mmol枸櫞酸三鈉(二水)294.122.075枸櫞酸(

17、一水)210.148.038葡萄糖(一水)198.1724.5120加注射用水至1000 mlRheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案準(zhǔn)備輸液泵將輸液管路與血濾管路的動(dòng)脈端相連接n最接近患者處(血泵前)根據(jù)患者病情, 設(shè)置血濾機(jī)的常規(guī)參數(shù)RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案ACD-A初始泵速為血液流速(BFR)的2.0 2.5%n泵速(ml/hr) = 1.2 1.5 x BFR (ml/min)例如nBFR = 120 ml/minnACD-A泵速 = 144 180 ml

18、/hrRheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案常規(guī)情況下選擇前稀釋方式RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案置換液中不含鈣RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣常規(guī)置換液配方常規(guī)置換液配方0.9% NS2000 ml注射用水500 ml5% NaHCO3125 ml25% MgSO43 ml10% CaGlu20 ml15% KCl5 ml50% GS總量枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案準(zhǔn)備10%葡萄糖酸鈣溶液及注射器泵將輸液管路連接至血濾管路靜脈端

19、葡萄糖酸鈣溶液初始泵速為8.8 11.0 ml/hr (ACD-A泵速的6.1%)RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案: 抗凝監(jiān)測(cè)抗凝監(jiān)測(cè)Q2h x 4Q4h x 4Day 1Day 2Q 6 8 h枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案: 抗凝監(jiān)測(cè)抗凝監(jiān)測(cè)RheaterACD-AVVPVPAUFBLDSAD枸櫞酸鈣動(dòng)脈標(biāo)本動(dòng)脈標(biāo)本外周靜脈或動(dòng)脈外周靜脈或動(dòng)脈游離鈣游離鈣1.00 1.20 mmol/L靜脈標(biāo)本靜脈標(biāo)本濾器后血濾管路濾器后血濾管路游離鈣游離鈣0.20 0.40 mmol/L枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案: 抗凝監(jiān)測(cè)抗凝監(jiān)測(cè)靜脈標(biāo)本游離鈣靜脈標(biāo)本游離鈣從濾器后靜脈取血部位取血從濾器后靜脈取血部位取血ACD-A輸注速度調(diào)整輸注速度調(diào)整 0.50 mmol/L增加10 ml/hr枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案: 抗凝監(jiān)測(cè)抗凝監(jiān)測(cè)動(dòng)脈標(biāo)本游離鈣動(dòng)脈標(biāo)本游離鈣從外周靜脈或動(dòng)脈取血從外周靜脈或動(dòng)脈取血10%葡萄糖酸鈣輸注速